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Educational PurposeThis curriculum deck will update readers on recent advances regarding the use of analgesia and sedation in acute care settings.

Learning ObjectivesUpon completion of this activity, participants should be able to

Describe the rationale for the use of analgesia and sedation in acute care settingsCompare the current analgesics and sedatives, and assess their benefits and limitationsReview the clinical study evidence supporting the use of currentagents for acute care sedation and analgesiaDiscuss the rationale for pharmacoeconomic analyses of therapeutic agents in various acute care settings

Program Overview

General Anesthesia and Sedation BackgroundComfort Care in the Acute Care SettingOverview of Current Sedative and Analgesic AgentsDexmedetomidinePharmacoecononmic DataNeurological EffectsPediatric ApplicationsDexmedetomidine in Bariatric SurgeryAlgorithmsSummary

General Analgesia and

Sedation Background

Purpose of Analgesia and Sedation in Acute Care Settings

Provide adequate pain control1Optimize safety for patients and their caregivers2

Enhance patient comfort1Facilitate mechanical ventilation3

Reduce anxiety1

Prevent delirium1

Induce sleep when required1

Induce appropriate level of amnesia3

1Ely EW, et al. JAMA. 2003;289:2983-2991.2Blanchard AR. Postgrad Med. 2002;111:59-74.

3Kress JP, et al. Am J Respir Crit Care Med. 2002;166:1024–1028.

Need for Analgesia and Sedation in Acute CarePhysiological and Neurobehavioral Considerations

• Failure to address pain in acute care patients may lead to– Agitation and anxiety– Hypermetabolic states – Increased endogenous catecholamine activity – Myocardial ischemia

• Acute care patients may demonstrate periods of disorientation during which psychotic behavior occurs

• Certain types of sedation can reduce the risk of harm to the patient or others

Kress JP, et al. Am J Respir Crit Care Med. 2002;166:1024–1028.

Factors Leading to Agitation

Modifiable Non-Modifiable

Inconsiderate Providers1

Alarms1

Lights/Temperature1

Mechanical Devices1

Loss of Control1

Nonchanging Environment

Sleep Deprivation1

Noises1

Memory Loss1

Confusion1

Fear1

Medications1,2 Surgical Stress1

Chemical/PhysiologicImbalance1

Pain

Anxiety

Agitation

Delirium

Age/History1

1ASHP Therapeutic Guidelines. Best Practices for Heath-System Pharmacy. 2003-2004;486-512.2McKinley S, et al. Am J Crit Care. 2004;13:146-152.

Goals of Sedation and Analgesia

Optimize safety for acute care patients and their caregivers1,2

Relieve pain and anxiety1-3

Attenuate the harmful adrenergic response1,2

Improve compliance with care1,2

Facilitate communication with caregivers and family members1,2

Avoid or reduce delirium1,2,4

1Blanchard AR. Postgrad Med. 2002;111:59-74.2Jacobi J, et al. Crit Care Med. 2002;30:119-141.

3Dasta JF, et al. Pharmacotherapy. 2006;26:798-805.4Ely EW, et al. JAMA. 2004;291:1753-1762.

Characteristics of an Ideal Sedative

Rapid onset of action allows rapid recovery after discontinuation1

Effective at providing adequate sedation with predictable dose response1,2

Easy to administer1,3

Lack of drug accumulation1

Few adverse effects1-3

Minimal adverse interactions with other drugs1-3

Cost effective3

Predictable dose response2

Promotes natural sleep4

1Ostermann ME, et al. JAMA. 2000;283:1451-1459. 2Jacobi et al. Crit Care Med. 2002;30:119-141.

3Dasta JF, et al. Pharmacotherapy. 2006;26:798-805..4Nelson LE, et al. Anesthesiology. 2003;98:428-436.

Targeting Patient Comfort

Oversedation

Undersedation

On-target sedation:Decreases weaning period1

Is not associated with muscular atrophy1

Decreases LOS and cost2Provides cardiovascular1

and intraoperative hemodynamic stability3

Improves patient safety1,3

Facilitates neurological assessment3

On-Target

Sedation

1McGaffigan PA. Crit Care Nursing. 2002;Feb Suppl:29-36.2Dasta et al. Pharmacotherapy. 2006;26:798-805.

3Arbour R. Am J Crit Care Nursing. 2004;13:66-73.

Importance of Optimizing Levels of Sedation

Undersedation OversedationAnxiety1 Prolonged weaning3

Ventilator dysynchrony2 Respiratory depression4

Dislodging invasive lines/ devices1

Lack of patient cooperation for assessment and therapeutic measures1

May increase posttraumatic stress syndrome1

Inability to communicate with health care providers or family members1

Increased O2 consumption1 Delirium2

Delirium2 Hypoactivity1

Hyperactivity1

Minimal amnesia2

1McGaffigan PA. Crit Care Nursing. 2002;Feb Suppl:29-36.2ASHP Therapeutic Guidelines. Best Practices for Heath-System Pharmacy. 2003-2004;486-512.

3Carrasco G. Crit Care. 2000;4:217–225.4Blanchard AR. Postgrad Med. 2002;111:59-74.

Incidence of Inadequate Sedation

15.4%

30.6%

54.0%

Undersedated1

Oversedated1

On-Target1

Continuous sedation carries the risks associated with oversedation and may increase the duration of mechanical ventilation (MV)1,2

MV patients accrue significantly more cost during their ICU stay than non-MV patients 3

– $31,574 versus $12,931, P<.0013

Sedation should be titrated to achieve a cooperative patient and daily wake-up, a JCAHO requirement2,3

1Kaplan L, et al. Crit Care. 2000;4(suppl 1):S110.2Kress et al. N Engl J Med. 2000;342:1471-1477.

3Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.

Costs and Effects of Undersedation

• Increased staffing needs (nursing and respiratory care)1

• Patient/family discomfort and dissatisfaction

• Decreased staff satisfaction• Need for an appropriate use of paralysis• Adverse physiologic consequences• Reflex shift to oversedation

• Inability to adequately examine the patient

• Increased costs of diagnostic imaging and other tests

• Possible delayed diagnosis of treatable problems

• Prolonged mechanical ventilation time

• Prolonged stay in acute care settings

• Prolonged hospital stay

Costs and Effects of Oversedation

On-Target

Sedation

OversedationOversedation

UndersedationUndersedation

1Kress JP, et al. N Engl J Med. 2000;342:1471-1477.

Guidelines and Standards

JCAHO Standards 2002 SCCM GuidelinesAnesthesia Patient Safety FoundationASA GuidelinesInstitute of Medicine

Comfort Care in the

Acute Care Setting

Assessing Pain

Faces Pain Rating Scale1

Visual Analog Scale (VAS)1

Pain questionnaire1

– Qualitative aspects1

Sympathetic response to pain1

1Jacox A, et al. Management of Cancer Pain. AHCPR publication 94-0592. 1994.

Assessing Sedation

Ramsay Sedation Scale

Observer’s Assessment of Alertness/Sedation Scale (OAA/SS)

Motor Activity Assessment Scale (MAAS)

Riker’s Sedation-Agitation Scale (SAS)

Richmond Agitation-Sedation Scale (RASS)

Brain function monitoring

Assessing Anxiety and Delirium

State-Trait Anxiety Inventory (STAI)1

Hamilton Rating Scales for Depression and Anxiety2

The Hospital Anxiety and Depression Scale3

Linear Analog Anxiety Scale4

Surrogate markers of stress response5

The Confusion Assessment Method for the Diagnosis of Delirium in the ICU (CAM-ICU)6

1Shedletsky R, et al. J Pers. 1974;42:511-527.2Hamilton M. Br J Soc Clin Psychol. 1967;6:278-296.

3Zigmond, AS, et al. Acta Psychiatr Scand. 1983;67:361-370. 4Sriwatanakul K, et al. Clin Pharmacol Ther. 1983;34:234-239.

5Lewis KS, et al. Am J Hosp Pharm. 1994;51:1539-1554.6 Ely EW, et al. Crit Care Med. 2001; 29:1370–1379.

Characteristics of Cooperative Sedation

In cooperative sedation, patients easily transition from sleep to wakefulness and task performance when aroused1

Patients are able to resume rest when not stimulated1

Cooperative sedation is most useful during procedures in which communication with the patient must be maintained1

Facilitates participation in therapeutic maneuvers2

Allows for patient interaction in care decisions2

May contribute to shorter recovery room convalescence3

Reduces risk of developing drug-induced complications3

1Bekker AY, et al. Neurosurgery. 2005;57(1 Suppl 1):1-10.2Burns AM, et al. Drugs. 1992;43:507-515.

3Sedation. Encyclopedia of Medicine. Ed. Jacqueline L. Longe. Thomson Gale, 2002. eNotes.com. 2006. 6 Mar, 2006 http://health.enotes.com/medicine-encyclopedia/sedation

Examples of Cooperative Sedation

Allows for accurate evaluation of the neuropsychological status of mechanically ventilated patients1

Facilitates direct evaluation of cerebral perfusion during carotid endarterectomy2

Patients are comfortable and responsive during cortical mapping2

1Bekker AY, et al. Neurosurgery. 2005; 57(1 Suppl):1-10. 2Ard JL, et al. Surgical Neurology. 2005;63:114-117.

Negative Outcomes Associated With Poor Cooperative Sedation

Pain that is not communicated in acute care settings can result in1

– Increased stress response– Guarding of muscles and muscle rigidity around

area of pain, leading to pulmonary dysfunction– Exhaustion and disorientation– Poor patient cooperation

Inability to assess patients can result in– Increased number of diagnostic tests– Increased time on ventilator– Increased LOS– Increased overall costs

1Jacobi J, et al. Crit Care Med. 2002;30:119-141.

Institutional Effects of Implementing Rational Use Guidelines

Prospective analysis of 156 ICU patients who required mechanical ventilation and continuous analgesia, sedation, and/or neuromuscular blockade1

One group (n = 84) was tracked after guidelines were implemented1

Length of hospital and ICU stay and duration of mechanical ventilation were all shorter in the guidelines group1

Institution of the guidelines led to a decline in mean drug costs across all drug classes studied1

1Mascia MF, et al. Crit Care Med. 2000;28:2300-2306.

Implementation of Clinical PathwaysClinical Outcome and Cost Burden

Large-scale implementation project with comparison to historic controls1

Outcomes management study including evidence-based clinical pathways and protocols for weaning acute care patients1

Participants included 595 pre-outcomes management patients and 510 post-outcomes management patients mechanically ventilated for >3 consecutive days1

1Burns SM, et al. Crit Care Med. 2003;31:2752-2763.

Implementation of Clinical PathwaysClinical Outcome and Cost Burden (Cont’d)

Significant differences in clinical outcomes were demonstrated between the 2 groups1

– Decreased ventilator duration by 1 day (P=.0001)1

– ICU stay reduced by 3 days (P=.0008)1

– Hospital length of stay reduced by 2 days (P=.0001)1

– Mortality rate declined from 38% to 31% (P=.02)1

More than $3 million cost savings were realized in the OM group1

1Burns SM, et al. Crit Care Med. 2003;31:2752-2763.

Overview of Current Sedative and

Analgesic Agents

Overview of Current Sedative and Analgesic Agents

Drug Class Examples Year FDA Approved

Opioids Morphine Prior to 1938Fentanyl 1968

Butyrophenones Haloperidol 1967

Sedatives/hypnotics Propofol 1989α2 Agonists Clonidine 1986

Benzodiazepines Diazepam 1963Lorazepam 1963Midazolam 1985

Dexmedetomidine 1999

http://www.fda.gov/cder/ob/default.htm

Opioids

Clinical EffectsAnalgesia1

Sedation1

1Harvey MA. Am J Crit Care. 1996;5:7-16.2Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453.

3Dean AJ, et al. J Psychiatry Neurosci. 2006;31:38-45.4Gerra G, et al. Drug Alcohol Depend. 2004;75:37-45.

MorphineFentanyl

Adverse EffectsRespiratory depression1,2

Hypotension1,2

Bradycardia1,2

Constipation1

Tolerance1

Withdrawal symptoms1,2

Dysphoria3,4

Haloperidol

Clinical Effects

Hypnotic agent with antipsychotic properties1

– For treatment of delirium in critically ill adults1

Does not cause respiratory depression1

1Harvey MA. Am J Crit Care. 1996;5:7-16.2Crippen DW. Crit Care Clin. 1990;6:369-392.

FO

NOH

CI

Haloperidol

Adverse Effects

Dysphoria2

Adverse CV effects include QT interval prolongation, extrapyramidal symptoms, neuroleptic malignant syndrome (rare)1

Metabolism altered by drug-drug interactions2

Benzodiazepines Lorazepam

Clinical EffectsSedation, anxiolysis, and amnesia1

Commonly used for long-term sedation2

Adverse EffectsSlower onset of action than midazolam2,3

Metabolic Acidosis (propylene glycol toxicity)4,5

Retrograde and anterograde amnesia can exceed desirability6

Delirium7

1Lerch C, et al. Br Med Bull. 1999;55:76-95. 2Shafer A. Crit Care Med. 1998;26:947-956.

3Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453.4Neale BW, et al. Ann Pharmacother. 2005;39:1732-1736.

5Wilson KC, et al. Chest. 2005;128:1674-1681.6Mathew A, et al. Psychpharmacol. 2002;16:345-354.

7Pandharipande P, et al. Anesthesiology. 2006;104:21-26.

BenzodiazepinesMidazolam

Clinical EffectsSedation, anxiolysis, and amnesia1

Rapid onset of action intravenously1

1Blanchard AR. Postgrad Med. 2002;111:59-74.2Harvey MA. Am J Crit Care. 1996;5:7-16.

3Shafer A. Crit Care Med. 1998;26:947-956. 4Midazolam [package insert]. Weston, FL: Apotex Corp; 2000.

Adverse EffectsMay accumulate in liver and/or renal failure1

Anterograde amnesia2

Prolonged recovery after long-term use3

Combination with opioids increases hypotensive effects1

Respiratory depression4

Adverse hemodynamic events have been reported in pediatric patients with cardiovascular instability4

Propofol

Clinical EffectsSedation1

Hypnosis1

Anxiolysis1

Muscle relaxation1

↓ ICP1

↓ Cerebral metabolic rate1

Antiemetic2

Adverse EffectsRespiratory depression (exacerbated by opioids)1

Hypotension1

Decreased myocardial contractility3

Preservative issues4

Potential for infection4

Tolerance5

Propofol infusion syndrome6

↑ Serum triglycerides4

1Harvey MA. Am J Crit Care.1996;5:7-16.2Apfel CC, et al. Anaesthesist. 2005;54:201-9.

3Lerch C, et al. Br Med Bull. 1999;55:76-95.4Diprivan [package insert]. AstraZeneca Pharmaceuticals; 2004.

5Zapantis A, et al. Crit Care Nurs Clin N Am. 2005;17:211-223.6Riker RR, et al. Pharmacotherapy. 2005;25(5 Pt 2):8S-18S.

(CH3)2 CH CH (CH3)2

OH

α2 Agonists: Clonidine

Clinical EffectsAntihypertensive1,2

Analgesia1

Anxiolysis1

Sedation1

↓ Shivering1

N

N

H

N

Cl

Cl

Clonidine

Adverse EffectsBradycardia1

Dry mouth1

Hypotension3

1Kamibayashi T, et al. Anesthesiology. 2000;93:1345-1349; 2Catapres [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc; 2004. 3Nishima K, et al. Anesthesiology. 2004;59:323-329.

α2 Agonists: Dexmedetomidine

Clinical EffectsAntihypertensive1,2

Sedative1,2

Analgesic1,2

↓ Shivering3

Anxiolytic effects4

Patient rousability4

Potentiates effects of opioids, sedatives, and anesthetics2

Decreased sympathetic activity5

Dexmedetomidine

CH3

CH3

N

N

CH3H

Adverse EffectsBradycardia6

Hypotension6

Dry mouth2

Vasoconstriction with rapid infusion or at high doses2

Nausea2

1Kamibayashi T, et al. Anesthesiology. 2000;93:1345-1349.2Precedex [package insert]. Lake Forest, IL: Hospira Inc; 2004.

3Doufas AG, et al. Stroke. 2003;34:1218-1223.4Riker RR, et al. Pharmacotherapy. 2005;25(5 Pt 2):8S-18S.

5Venn RA, et al. Brit J Anaesthesia. 2001;87:684-690.6Shehabi Y, et al. Intensive Care Med. 2004;30:2188-2196.

Saper CB, et al. Nature. 2005;437:1257-1263.

Key Components of theAscending Arousal System

Key Projections to theAscending Arousal System


“Switch” Mechanisms of Alertness and Sleep

Sleep

VLPOeVLPO

LCTMNRaphe

Awakea LC

TMNRaphe

VLPOeVLPO

ORX

On

ORXb

Off


Clinical Characteristics of Dexmedetomidine

Cooperative sedation1

Analgesia2,3

Organ Protection (ie, neural, renal, cardiac)1

Anxiolysis2,3

Controls hyperadrenergic response to stress1-3

Reduces shivering3

Diuretic action4

Mimics Natural Sleep1

1Aantaa R, et al. Drugs of the Future. 1993;18:49-56.2Kamibayashi T, et al. Anesthesiology. 2000;93:1345-1349. 3Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453.

4Goodman LS, et al. The Pharmacological Basis of Therapeutics. New York, NY: McGraw-Hill;2004:232-235.

Anxiolysis

α2B

X

Physiology of Dexmedetomidine

Reprinted with permission from Kamibayashi T, et al. Anesthesiology. 2000;93:1346.

α2A, α2C Locus Ceruleus

α2B CNS-based thermoregulatory inhibition

α2B Cerebral vessels and peripheral vasculature

α2A Peripheral smooth-muscle cells

α2A Dorsal horn of the spinal cord

α2A Brainstem vasomotor center

Blocks cardioaccelerator nerve

Vagomimetic action

Comparison of Clinical EffectsBenzo-

diazepines Propofol Opioids Dexmedetomidine Haloperidol

Sedation X X X X X

Alleviate anxiety1,2 X X

Analgesic Properties1-4 X X

Promote arousability during sedation2-4

X

Facilitate ventilation during weaning2-4 X

No respiratorydepression1-4 X X

Control delirium1-4 X X

1Blanchard AR. Postgrad Med. 2002;111:59-74.2Kamibayashi T, et al Anesthesiology. 2000;95:1345-1349.

3Maze M. et al. Anesthetic Pharmacology: Physiologic Principals and Clinical Practice. Churchill Livingstone; 2004.4Maze M, et al. Crit Care Clin. 2001;4:881.

Comparison of Adverse Effects

Benzo-diazepines Propofol Opioids Dexmedetomidine Haloperidol

X*

X

Tachycardia1 Morphine

X

X

X

X

X

Fentanyl

Prolonged weaning1 X X

Respiratory depression1 X X

Hypotension1-3 X X X

Constipation1

Deliriogenic X X

Bradycardia1 X

*Excluding remifentanil

1Harvey MA. Am J Crit Care. 1996;5:7-16.2Aantaa R, et al. Drugs of the Future. 1993;18:49-56.

3Maze M. Crit Care Clin. 2001;4:881;

Sedative-AnalgesicsRisk for Transitioning to Delirium

• Evaluation of 198 mechanically ventilated patients to determine the probability of daily transition to delirium1

– As a function of sedative and analgesic dose administration during the previous 24 hours1

• Lorazepam was an independent risk factor for daily transition to delirum1

Medication

Transitioning to Delirium Only Odds Ratio (95% CI) P Value

Lorazepam 1.2 (1.1-1.4) .003Midazolam 1.7 (0.9-3.2) .09Fentanyl 1.2 (1.0-1.5) .09

Morphine 1.1 (0.9-1.2) .24Propofol 1.2 (0.9-1.7) .18

1Panharipande P, et al. Anesthesiology. 2006;104:21-26.

Serious Complications Associated With Delirium

Prolonged ventilation 179 (20)Patient injury 179 (20)Respiratory complications 176 (19)Self-extubation 80 (9)Sepsis/shock 60 (7)Prolonged LOS 58 (6)Oversedation 52 (6)Death 36 (4)

Response Number (%)

Ely EW, et al. Crit Care Med. 2004;32:106-112.

Incidence of ICU Delirium

60 • Evaluation of 90 patients undergoing cardiac surgery to determine the probability of development of postoperative delirium1

• Post-operative sedation with dexmedetomidine may be associated with a lower incidence of delirium compared with more conventional forms of sedation1

50

Del

irium

, % 40

30

20

10

0

Dexmedetomidine Propofol Midazolam

Maldonado JR, et al. Anesthesiology. 2003; 99: A465.

Comparison of PharmacokineticsRanges Reported in Healthy Patients* and ICU Patients

0.32-0.64 mL/hr/kg2Dexmedetomidine3

1.9-4.36-23Clonidine2

17-316.3-32Propofol1

1.2-4.110-15 Lorazepam1

4.3-6.63.4-11Midazolam1

0.4-0.921-120Diazepam1

8.6-15.06.9-36.0Fentanyl18.6-232.0-5.5Morphine1

10-1328-38Haloperidol1

Hepatic/renal insufficiency

Hepatic impairment



Hepatic insufficiency



Renal insufficiency

–

Systemic Clearance

(mL/kg/min)EliminationHalf-life (hr)Agent

Potential for Accumulation4

*Healthy patients: no renal or hepatic disease.

3.45-4.5 L/h75Aripiprazole4,5

7.57Olanzapine4 --

7.57Ziprasidone4 Hepatic insufficiency


1Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453; 2Khan ZP, et al. Anaesthesia. 1999;54:146-165; 3Bhana N, et al. Drugs. 2000;59:263;

4Prescribing information for respective drugs; 5Mallikaarjun S, et al. J Clin Pharmacol. 2004;44:179-187.

Dexmedetomidine

Arousability From Sedation During Dexmedetomidine Infusion

During cognitive and cold pressor testingJust prior to cognitive and cold pressor testing

Dexmedetomidine Infusion

(mcg/kg/h)

0

20

40

60

80

100

Placebo 0.2 0.6

BIS

Patients were infused with placebo or 1 of 2 doses of dexmedetomidine and monitored with the Bispectral Index System (BIS) before stimulation and immediately after being asked to perform cognitive and cold pressor tests1

Patients receiving either infusion of dexmedetomidine could be completely aroused by a mild stimulus1

BIS indicates Bispectral Index System1Hall JE, et al. Anesth Analg. 2000;90:699-705.

Comparison of Dexmedetomidine With Propofol

20 adult ICU patients were randomized to either dexmedetomidine or propofol1– Dexmedetomidine; 10-minute 2.5 mcg/kg/h

loading dose, 0.2-2.5 mcg/kg/h maintenance dose1

– Propofol; ≤1 mg/kg 10-minute loading dose (if required), 1-3 mg/kg/h maintenance dose1

Additional analgesia, if necessary, was provided by alfentanil1Depth of sedation was measured with RSS and BIS1

Dexmedetomidine and propofol produced an equivalent depth of sedation1

1Venn RM, et al. Br J Anaesth. 2001;87:684-690.

Predictable Effects on Heart Rate and Arterial Pressure

1Venn RM, et al. Br J Anaesth. 2001;87:684-690. 2Venn RM, et al. Br J Anaesth. 2001;86:650-656.

5060708090

100110120

0 1 2 3 4 5 6 7 8

Mea

n H

eart

Rat

e, b

eats

/min

+4 +8 +12 +16 +20 +24

40557085

100115130145160175

0 1 2 3 4 5 6 7 8Mea

n A

rteria

l Pre

ssur

e, m

m H

g

+4 +8 +12 +16 +20 +24

Sedative Discontinued

PropofolDexmedetomidine

HeartRate

SBP

DBP

Significantly lower heart rates in the dexmedetomidine group during intubation (P=.034) but not after sedative discontinuation (P=.15)1

− Predictable 10% decrease with plateau1

No significant differences in systolic and diastolic blood pressures (P=.60)1

Attenuates postoperative tachycardia2

Note: Reductions from baseline shown.

Postoperative Effects of Dexmedetomidine

0

10

20

30

40

100

VAS

Pain

Less

Pai

nM

ore

Pai

n PropofolDexmedetomidine

Improved postoperative pain and greater sedation with dexmedetomidine compared with propofol1

* †

0

40

60

80

100

VA

S S

edat

ion

Less

Ale

rtM

ore

Ale

rt

* †

Pre-surg

SurgEnd

5 35 50 6520

Time After Surgery, minutes

*P<.05 difference over time compared with baseline†P<.05 difference between groups

1Arain SR, et al. Anesth Analg. 2002;95:461-466.

Morphine-Sparing Effects in Inpatient Surgery

34 patients scheduled for inpatient surgery1

Randomized to either dexmedetomidine or morphine1

Agents were started 30 minutes before the end of surgery1

Dexmedetomidine reduced the early postoperative need for morphine by 66%1

0

2.5

5

7.5

10

12.5

Morphine Dexmedetomidine

Ave

rage

Tot

al M

orph

ine

Use

d, m

g

P<.01

0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

Minutes in PACU

Cum

ulat

ive

Mor

phin

eU

sed,

mg

MorphineDexmedetomidine

P<.01

1Arain SR, et al. Anesth Analg. 2004;98:153-158.

Reduction of Postoperative Requirement for Epidural Opioids With Dexmedetomidine

Prospective, randomized, double-blind study with 28 patients scheduled for thoracotomy for wedge resection, lobectomy, or pneumonectomy1

Bupivacaine was administered in an acute care setting through a thoracic epidural, and patients were randomized to receive either IV placebo or IV dexmedetomidine (20-minute, 0.5 mcg/kg loading dose plus infusion of 0.4 mcg/kg/h)1

Supplemental analgesia (fentanyl), vital signs, and blood gasses were monitored1

1Wahlander S, et al. J Cardiothorac Vasc Anesth. 2005;19:630-635.

Reduction of Postoperative Requirement for Opioids With Dexmedetomidine

Requirement for Supplemental Epidural (ED) FentanylThe requirement for supplemental ED fentanyl analgesia was significantly greater in the placebo group1

Dexmedetomidine is a potentially effective analgesic adjunct to thoracic ED bupivacaine infusion and may decrease the requirement for opioids and potential for respiratory depression1

66.1

5.3

01020304050607080

Placebo Dexmedetomidine

Tota

l Fen

tany

l Use

d, m

cg P=.039

1Wahlander S, et al. J Cardiothorac Vasc Anesth. 2005;19:630-635.

Injury and Liability Associated With Monitored Anesthesia Care

Bhananker and colleagues assessed the patterns of injury and liability associated with monitored anesthesia care (MAC; n = 121) compared with general (n = 1519) and regional anesthesia (n = 312)The proportion of claims for death and permanent brain damage was reduced in regional anesthesia compared with MAC In contrast, the severity of injury was similar between MAC claims and those associated with general anesthesia

0

10

20

30

40

50

60

Death/Perm BrainDamage

Permanent Disabling Temp/Nondisabling

MAC General Regional

*

*

*

*

* P<.025 MAC versus Regional

Cla

ims

in A

nest

hesi

a G

roup

, %

Bhananker S, et al. Anesthesiology. 2006;104:228-34.

Injury and Liability Associated With Monitored Anesthesia Care (Cont’d)

Respiratory depression due to sedative, hypnotic, and/or analgesic overdose was responsible for 21% of MAC-related claims – 24% occurred during endoscopic procedures– Nearly 75% received a combination of two or more drugs

• Either a benzodiazepine and an opioid or propofol plus others

Death or brain damage resulted in most of the claims related to oversedationResolution of legal claims associated with oversedation cost an average of $254,000 per patient

Bhananker S, et al. Anesthesiology. 2006;104:228-34.

Pharmacoeconomic Data

Factors Affecting ICU Cost

ICU stays account for nearly a third of total inpatient costs1

High ICU costs may be due to mechanical ventilation (MV) and/or delirium1,2

Sedatives have the potential to prolong MV and may increase healthcare costs3,4

Incorporation of a daily sedation interruption policy into a medical ICU guideline can significantly reduce ICU stays and days of MV5

1Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.2 Milbrant EB, et al. Crit Care Med. 2004;32:955-962.

3Ostermann ME, et al. JAMA. 2000;283:1451-1459.4MacLaren R, et al. Pharmacotherapy. 2005;25:1319-1328.

5Wittbrodt ET. Pharmacotherapy. 2005;25(5 Pt 2):3S-7S.

Limitations of Pharmacoeconomic Studies on Sedation

Small sample sizes1

Results not applicable to other clinical sites1

Too few have been conducted to date1

Most do not evaluate total cost1,2

1Ostermann ME, et al. JAMA. 2000;283:1451-1459.2MacLaren R, et al. Pharmacotherapy. 2005;25:1319-1328.

Pharmacoeconomic AnalysisOutcomes Analysis in Cardiac Surgery

12-month retrospective administrative claims database analysis (2003-2004)1

Nationally representative sample of 250 medical and surgical hospitals1

Comparison of patients receiving either midazolam plus propofol (M+P, n = 9996) or dexmedetomidine plus M+P (D+M+P, n = 356)1

– Patients who were admitted to the hospital for either a cardiovascular valve or vessel procedure1

– Patient demographics and outcomes were obtained from the hospital billing claim form, UB-921

Admissions with lengths of stay more than 100 days were excluded from all analyses

1Dasta JF, et al. Pharmacotherapy. 2006;26:798-805.

Pharmacoeconomic AnalysisBaseline Characteristics

CharacteristicM+P

n = 9996D+M+Pn = 356 P-Value

Age, y (mean [SD]) 65.6 (12.0) 61.0 (11.1) <.0001Male 67.6% 78.9% <.0001Patient Charlson Comorbidity Index <.05

0 34.4% 40.2%1 56.7% 53.7%2 7.6% 4.5%3 1.0% 1.6%4 0.3% 0%

Mechanical Ventilation/IntubationPatients 78.1% 98.0% <.0001Duration, days 5.46 4.82 <.01


Pharmacoeconomic AnalysisReduced Mean Total Treatment Charges

$106K

$89K

0

20

40

60

80

100

120

M+P D+M+P

Trea

tmen

t Cha

rges

, $Th

ousa

nds

P<.05 12-month retrospective administrative claims database analysis1

Comparison of patients receiving either midazolam plus propofol (M+P) or dexmedetomidine plus M+P (D+M+P)1

The D+M+P cohort showed significant reductions in per patient total charges1

M+P, n = 9996D+M+P, n = 356


Pharmacoeconomic AnalysisDepartmental Treatment Charges

$17.7K

$2.8K

02468

101214161820

M+P D+M+P

Cha

rges

, $Th

ousa

nds P<.0001

ICU/CCU

$12.7K

$16.7K

02468

1012141618

M+P D+M+P

Cha

rges

, $Th

ousa

nds P<.0001

Pharmacy

$17.3K

$12.8K

02468

101214161820

M+P D+M+PC

harg

es, $

Thou

sand

s P<.0001Operating Room

$2.5K

$3.4K

0

1

2

3

4

M+P D+M+P

Cha

rges

, $Th

ousa

nds P<.0001

Anesthesia

M+P, n = 9996D+M+P, n = 356

Reductions in ICU and OR charges offset increases in other areas


Pharmacoeconomic AnalysisReduced Hospitalization and Mortality

Mean Length of Stay Mean Days in ICU/CCU Mortality RateP<.0001 P<.0001 P=.0142

5.3

1.4

0

1

2

3

4

5

6

M+P D+M+P

Mea

n D

ays

9.48.8

0

1

2

3

4

5

6

7

8

9

10

M+P D+M+P

Mea

n D

ays

3.0%

1.0%

0

1

2

3

4

M+P D+M+P

Mor

talit

y R

ate,

%M+P, n = 9996D+M+P, n = 356


Pharmacoeconomic AnalysisReduced Charges, Hospitalization, and Mortality in

Patients With Cardiac Vessel Procedures

Mean Total Charges Mean Length of Stay Mortality Rate

$97K

$80K

0

20

40

60

80

100

120

M+P D+M+P

Cha

rges

, $Th

ousa

nds

P<.05 P<.01 P=.1074

8.98.1

0

1

2

3

4

5

6

7

8

9

10

M+P D+M+P

Mea

n D

ays

2.5%

1.0%

0

0.5

1

1.5

2

2.5

3

M+P D+M+P

Mor

talit

y R

ate,

%M+P, n = 7577D+M+P, n = 293


Pharmacoeconomic AnalysisStudy Limitations

DosageDuration of therapies Influence of practice patterns/institutional variability unknown Lack of randomization of patients to treatment introduced risk of selection or channeling biasAssigning causality based on results not possible1


Pharmacoeconomic AnalysisStudy Conclusions

Dexmedetomidine was added to standard sedative regimens (midazolam + propofol) under actual practice conditions1

Largest study measuring the pharmacoeconomic and clinical outcomes of any sedation agent in this populationPotential demonstrable clinical and economic benefits of including dexmedetomidine in sedation regimens1

– Addition of dexmedetomidine to the standard of care was associated with significant reductions in total LOS, stay in ICU/CCU, and mortality1

– Significantly lower total treatment charges1


Properties of Dexmedetomidine in Cardiovascular Surgery

Lack of respiratory depressionCooperative sedation aids in assessing neurophysiological function during vascular procedures such as endarterectomy Hemodynamic stabilization is desirable during cardiovascular surgeryAttenuates hypertension and tachycardia

Aantaa R, et al. Eur J Anaesthesiol. 2006;23:361-372.

Postoperative CABG Sedation Dexmedetomidine Versus Propofol

Effects of Dexmedetomidine and Propofol on Heart Rate

Mean heart rates were similar between groups throughout the study period1

-10

-5

0

5

10

15

10 20 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Mea

n H

eart

Rat

e C

hang

e, b

eats

/min

Time, hoursMinutes

PropofolDexmedetomidine

1Herr DL, et al. J Cardiothorac Vasc Anesth. 2003;17:576-584.

Immediate Extubation Following Cardiac Surgery

Horswell et al conducted a study of immediate extubation after off-pump coronary artery bypass graft (OPCAB) in 514 patientsFollowing surgery, each patient received 2 or more of the following: epidural anesthesia, IV morphine on demand, IV ketorolac on schedule, and/or continuous IV dexmedetomidineAll patients were successfully extubated immediately after dressing applicationThe investigators concluded that immediate extubation of OPCAB patients is feasible and probably safe1

1Horswell JL, et al. J Cardiothorac Vasc Anesth. 2005;19:282-287.

Use of Perioperative Dexmedetomidine in Vascular Surgery

Significant between group changes from baseline for plasma epinephrine (P<.05) and norepinephrine (P<.001) Plasma norepinephrine concentrations were 2 to 3 times lower in the dexmedetomidine group at both tracheal extubation and at 60 min after arrival to PACU Plasma epinephrine concentrations were lower in the dexmedetomidine group only during tracheal extubation

1Talke P, et al. Anesth Analg. 2000;90:834-839.

Dexmedetomidine Placebo

200

250

300

350

100

150

mg/gm creatinine

Metanephrine

baseline intraop POD1 AM POD1 PM POD2 AM POD2 PM

5

4

2

3

1

0

nmol/mL

Epinephrine

baseline preop intub extub PACU PACU+60

#*

* *

200

300

400

500

600

700

800

900

1000

1100mg/gm creatinine

Normetanephrine

baseline intraop POD1 AM POD1 PM POD2 AM POD2 PM

#*

#*#

*

10

8

9

7

6

5

4

2

1

3

1

nmol/mL

Norepinephrine

baseline preop intub extub PACU PACU+60

#*

#*

*

# Significantly different (P<.05) from dexmedetomidine group. * Significantly different (P<.05) from baseline.

Neurological Effects

Properties of Dexmedetomidine in Neurosurgery

Intraoperative hemodynamic stability1

Lack of respiratory depression1

Patients easily transition from sleep to wakefulness and task performance when aroused, and then back to sleep when not stimulated1

Does not increase intracranial pressure1

Allows for consistent and reliable somatosensory evoked potential amplitudes or latencies1

1Bekker A, Sturaitis MK. Neurosurgery. 2005;57:1-10.

Examples of Cooperative SedationNeurological Examples

Intracranial surgical procedures often require patient cooperation for functional assessment1– The procedure is frequently limited by the location/spatial extent

of the lesion and its relationship to functioning tissue1

– Surgeons balance the benefits of an aggressive resection with anticipated neurological dysfunction1

Intraoperative neurophysiological testing1

– Can verify that surgical target has been localized1

– Is used to assess the production of an intended functional change1

Carotid endarterectomy performed in awake patients allows evaluation of cerebral perfusion by continuous examination of neurologic function2

1Bekker AY, et al. Neurosurgery. 2005; 57(1 Suppl):1-10.2Bekker AY, et al. J Neurosurg Anesthesiol. 2004;16:126-135.

Dexmedetomidine and Cerebral Blood FlowClinical Data

Reduced cerebral blood flow (CBF) has also been demonstrated in human studies1

– Reduced CBF may be advantageous for situations such as traumatic brain injury or large brain tumors1

No detrimental effect on local brain tissue oxygenation in patients undergoing cerebral vascular surgery1

Under normotensive conditions in the setting of compromised cerebral circulation, dexmedetomidine has no apparent adverse effects1

It has been shown that dexmedetomidine is suitable for preoperative sedation of patients with subarachnoid hemorrhage (SAH)2

1Bekker A, Sturaitis MK. Neurosurgery. 2005;57:1-10.2Sato K, et al. Masui. 2006;55:51-54.

Dexmedetomidine and Cerebral Blood FlowDecreased Cerebral Metabolic Rate

Prielipp and colleagues analyzed data from nine supine volunteers to assess the potential for dexmedetomidine induced decreases in regional and global CBF Patients were infused with a 1 mcg/kg IV loading dose of dexmedetomidine, followed by an infusions of either – 0.2 mcg/kg/h (Low Dose) – 0.6 mcg/kg/h (High Dose)

Prielipp RC, et al. Anesth Analg.2002;95:1052-1059.

Dexmedetomidine and Cerebral Blood FlowDecreased Cerebral Metabolic Rate

Both low and high doses– Reduced global CBF by

one third– Decreased mean

systemic BP, HR, and CO 15% to 20%

– Increased PaCO2 no more than 5 mm Hg

CBF decreased from baseline throughout dexmedetomidine infusion and for at least 30 minutes thereafter

Baseline Low Infusion High Infusion 30 min post-termination

Note: Color intensity correlates with CBF

Prielipp RC, et al. Anesth Analg.2002;95:1052-1059.

Dexmedetomidine and Cerebral Blood FlowCerebral Perfusion in Severe Head Injury

Prospective study on the effect of dexmedetomidine in patients with severe head injury

– 12 ICU patients (aged 15 to 64 years) – Glasgow Coma Scale <8– Intracranial pressure <20 mm Hg – O2 saturation monitoring of blood from jugular bulb

3 hours of progressive IV dexmedetomidine perfusion (0.2, 0.4, 0.7 mcg/kg/h)

– All other sedative-analgesic medications previously withdrawn

Grille P, et al. Neurocirugia. 2005;16:411-8.

Dexmedetomidine and Cerebral Blood FlowCerebral Perfusion in Severe Head Injury (Cont’d)

No significant changes from baseline in the following domains– Intracranial

pressure– Mean arterial

pressure– Cerebral

profusion– Jugular bulb

oxygenation– Cerebral

oxygen extraction/ supply

– Heart rate

60

65

7570

80

8590

201510

25

3540

30

906030 120 150 180

100

110

60

50

70

80

90

120

90600 30 120 150 180

# ## # ##

*

* * 10

906030 120 150 180

0

0

5

-5

60

80

100

100

20

20

30

120

906030 120 150 180

1400

10

80

Time (min)

Time (min)

Cha

nge

in In

tracr

ania

l Pr

essu

re D

urin

g Se

datio

nC

ereb

ral

Perfu

sion

Intra

cran

ial

Pres

sure

0

Time (min)

Time (min)

Hea

rt R

ate

Cer

ebra

l O2

Jugu

lar O

2

0

MAP

# P<.05* P<.001 1Grille P, et al. Neurocirugia. 2005;16:411-8.

Pediatric Applications

Use of Dexmedetomidine in MRI

80 children aged 1-7 years1

Randomly assigned to either dexmedetomidine or midazolam1

– 10-minute loading doses: 1 mcg/kg dexmedetomidine, 0.2 mg/kg midazolam1

– Infusions: 0.5 mcg/kg/h dexmedetomidine, 6 mcg/kg/h midazolam1

The quality of MRI was significantly better (P<.001) and the rate of adequate sedation was significantly higher (P<.001) with dexmedetomidine1

0

10

20

30

40

1 2 3

Num

ber o

f Pat

ient

s

MidazolamDexmedetomidine

1 = no motion2 = minor movement3 = major movement necessitating another scan

Quality of MRI

*P<.001 compared with midazolam

*

*

1Koroglu A, et al. Br J Anaesth. 2005;94:821-824.

Dexmedetomidine Superior to Midazolam in Pediatric Acute Care Patients

Reduced Need for Morphine• 20 pediatric ICU patients randomized to either dexmedetomidine (starting dose 0.25 or 0.5 mcg/kg/h) or midazolam (starting dose 0.1 mg/kg/h)1

• Morphine was used intermittently as needed1

• 0.25 mcg/kg/h dexmedetomidine was equivalent to 0.22 mg/kg/h midazolam1

• 0.5 mcg/kg/h dexmedetomidine provided more effective sedation than 0.22 mg/kg/h midazolam1

– Less morphine use1

– Decrease in the number of Ramsay scores of 1 (fewer patients oversedated)[Data not shown]1 0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Midazolam 0.25 0.5

Tota

l Mor

phin

e U

sed,

mg/

kg/2

4 h

Dexmedetomidine

*

*P=.01 compared with midazolam

mcg/kg/h

1Tobias JD, et al. South Med J. 2004;97:451-455.

Propofol Black Box Warnings for Pediatric Use

Not recommended for – Induction of anesthesia in patients aged <3 years1

– Maintenance of anesthesia in patients aged <2 months1

Pediatric use– Not indicated for ICU sedation or for MAC

sedation for surgical, nonsurgical, or diagnostic procedures1

– Co-administration of fentanyl and propofol may result in serious bradycardia1

1Propofol [package insert]. Bedford, OH: Bedford Laboratories; 2005.

Dexmedetomidine in

Bariatric Surgery

Intraoperative Use of Dexmedetomidine in Bariatric Surgery

Rising incidence of morbid obesity is increasing the need for bariatric surgery1,2

Respiratory comorbidities in morbid obesity may profoundly impact anesthetic management1,2

– Opioid use may lead to severe respiratory depression1,2

– Ideal analgesics should be free of significant/long-lasting respiratory effects1,2

In one center, over 2000 bariatric procedures have been performed safely using the perioperative administration of dexmedetomidine, which was shown to be cardioprotective and neuroprotective while providing a hemodynamically stable course and reducing the need for opioids and inhalational agents3

1Hofer RE, et al. Can J Anaesth. 2005;52:176-180.2Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.

3Ramsay MA. Semin Anesth.2006;25:51-56.

Dexmedetomidine Attenuates Blood Pressure in Bariatric Surgery

Feld and colleagues evaluated whether dexmedetomidine infusion could replace fentanyl in open gastric bypass surgery1

During surgery, blood pressure and heart rate were significantly decreased with dexmedetomidine compared with fentanyl1

Dexmedetomidine was associated with significantly lower postoperative pain and morphine use1

1Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.

120

100

80

60

40

120

100

80

60

40

FentanylDexmedetomidine

Time (min)0 60 120 180

Mea

n Bl

ood

Pres

sure

(mm

Hg)

Hea

rt R

ate,

BPM

(min

-1)

Algorithms

Dexmedetomidine Sedation Algorithm

Peruzzi/NMH/NUMS Protocol. March, 2001.

Is the patient agitated or in pain? SAS >4?

Initial assessment of patient’s sedation level

Is the patient comfortable, cooperative, and communicative? SAS ≤4 ?

Initiate Dexmedetomidine• Begin infusion: 0.2 mcg/kg/hr

(If SAS<6 and hemodynamics are normal or depressed)• If hyperdynamic and SAS >6: Bolus, 1.0 mcg/kg over

10-20 minutes

Ongoing assessment of patient’s sedation level• SAS >4• Patient is agitated or in pain?

Dexmedetomidine infusion rate <0.7 mcg/kg/hr

Increase dexmedetomidine infusion rate <0.1 mcg/kg/hr

Assess pain and implement supplemental opioid protocol as needed

Implement supplemental agitation protocol (dexmedetomidine <2.0 mcg/kg/hr) if patient demonstrates agitation on assessment (SAS > 4)

N

N

Y

YIf the patient is somnolent or unresponsive with SAS <3, assess for CNS event, metabolic process, and drugs. If dexmedetomidine infusion is ongoing, decrease by 0.1 mcg/kg/hr with ongoing assessment of sedation.

N

N

YY

Y

Transitioning Long-Term Sedation to Dexmedetomidine

Titrate propofol every hour with orders not to increase

Administer dexmedetomidine infusion,

0.4 mcg/kg/hr

If extreme agitation occurs, add benzodiazepine (synergistic

with dexmedetomidine)

Titrate dexmedetomidine according to HR and BP

with allowed increases of 0.2 mcg/kg/hr

If patient is agitated on waking, administer more benzodiazepine

(requirement is less with dexmedetomidine on board)

Increase dose of dexmedetomidine in PM to optimize natural sleep

and circadian rhythm

Courtesy of Daniel L. Herr, MD.

Abdominal Aortic Aneurysm

Patients undergoing endovascular repair of abdominal aortic aneurysms with general (n = 217; 22 used for direct comparison) versus dexmedetomidine (n = 14) sedationDexmedetomidine sedation resulted in

– Reduced time for surgery – Reduced time for anesthesia– Reduced opioid requirement

Administer supplemental O2 via nasal cannulae

Initiate maintenance dexmedetomidine infusion (0.3 to 0.7 mcg/kg/h)

Cannulate arteries and insert grafts

Administer dexmedetomidine loading dose 1 mcg/kg via infusion pump

Administer 0.5% bupivacaine

Access femoral arteries via 2 small surgical incisions in both groins

Awaken patient and request holding of breath to induce apnea. Patient must remain still.

Complete procedure and bring patient to lighter sedation level prior to OR discharge

Brown BJ, et al. Proc (Bayl Univ Med Cent). 2006;19:213-215.

Neurosurgery Anesthesia Protocol

Induce as usual; when stable, start dexmedetomidine at 0.7 mcg/kg/h

After 15 mins reduce inhalant anesthetic to half MAC

Opioid use Routine dose of fentanyl at induction of anesthesia

Hemodynamics indicative of adequate analgesia?

Five minutes prior to end of procedure, reduce dexmedetomidine to 0.2 mcg/kg/h

Use supplemental opioid

Awaken patient and extubate

Titrate dexmedetomidine after extubation to patient comfort(usually 0.2 – 0.5 mcg/kg/h)

N

Y

Courtesy of M. Ramsay, MD.

Perioperative Bariatric Surgery AlgorithmPreoperative Protocol

Assess cardiac functioning Indications of cardiomegaly, cardiac failure, CAD, or pulmonary

HTN?

Optimize cardiac state Assess airway/

respiratory system

Y N

Obstruction of airway by adipose tissue?

Awake fiberoptic intubation

Obstructive sleep apnea?O2 Desaturation Risk?

↓ Lung VolumesFunctional residual capacity

Expiratory reserveForced vital capacity

N

Administer Dexmedetomidine (<0.7 mcg/kg/h) plus topical anesthetic

Correct head positioningUse “back up” position at induction

of anesthesia and subsequent recovery

Y

YN

Proceed to Intraoperative

Procedure


Perioperative Bariatric Surgery AlgorithmIntraoperative Protocol

Brief Procedure

Laproscopic gastric bypass or gastric banding

Roux-en Y gastric bypass

Y N

Dexmedetomidine solution400 mcg/100 mL of 0.9% sodium chloride at

4 mcg/mL

Initiate dexmedetomidine infusion (0.4 to 0.7 mcg/kg/h)

1 hour before completion of surgery

Reduce infusion at end of surgery (approximately 5 min prior to completion)

Administer Dexmedetomidine Loading Dose

0.5 to 0.75 mcg/kg and monitor for transient hypertension

Proceed to Postoperative Procedure

Allow patient to gradually awaken


Perioperative Bariatric Surgery AlgorithmPostoperative Protocol

Continue infusion in the recovery room during and after intubation

Titrate to 0.7 mcg/kg/h for

pain control

Discontinue dexmedetomidine at discharge from recovery unit

No postoperative opioids needed


Overall Summary

Patient care and safety, as well as physiological and neurobehavioral considerations, reinforce the need for sedation in acute care settingsAttenuating reactions to pain and stress while optimizing patient communication are important acute care goalsInappropriate sedation and analgesic therapy in acute care settings leads to poor clinical and economic outcomesGuidelines, standards, clinical pathways, and algorithms clarify the manner in which sedatives should be used in acute care settings– Institutions should have multidisciplinary agreements to

use scale assessment and documentation

Overall Summary (Cont’d)

Ongoing developments influence changes in guidelines and standards– It is anticipated that JCAHO will add new sedation criteria– Currently under revision, new SCCM guidelines are

expected in 2007

Implementation of rational use guidelines in acute care sedation can result in improved LOS and reduced costs for medications The addition of dexmedetomidine to the current standard of care is associated with improved clinical outcomes and reduced total hospital costs

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